Healthcare Provider Details

I. General information

NPI: 1477534634
Provider Name (Legal Business Name): MICHAEL FORBES WARDEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7155 W CAMPO BELLO DR STE C120
GLENDALE AZ
85308-8594
US

IV. Provider business mailing address

7155 W CAMPO BELLO DR STE C120
GLENDALE AZ
85308-8594
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-7301
  • Fax:
Mailing address:
  • Phone: 602-525-2109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1021
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1021
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: